Microneedling/Nanoneedling Information & Consent Form

First Name

Last Name

Address

City

State

Zip

Email

Cell Phone

Date of Birth

Emergency Contact Name

Emergency Contact Phone

What is Microneedling?

The procedure involves creating tiny, microscopic punctures in the epidermal layers of the skin using sterile stainless-steel needles which then stimulates neocollagenesis. I understand this device will not prevent me from developing or re-developing facial wrinkles and facial acne scars. Although this device is successful in most cases, no guarantees can be made. I understand I may not experience complete clearance, and that it may take multiple treatments. Some conditions may not respond at all, and in rare cases, may become worse. I understand that clinical results may vary depending on individual factors, including but not limited to medical history, skin type, patient compliance with pre- and post-treatment instructions, and individual response to treatment.

I have read and understand the above

Contraindications

Unfortunately not all treatments are for everyone. Please check our contraindications list.

Three to six treatments recommended every 4-6 weeks for best results. Conditions that would mean you were NOT able to have this treatment:

  • Hemophilia, blood clotting problems (ie poor wound healing)
  • Papulopustular rosacea
  • Acne Vulgaris stage III-IV
  • Solar Keratosis
  • Undergoing chemotherapy or immunotherapy
  • Connective tissue disorders / autoimmune disorders (e.g. lupus)
  • Long term use of Prednisone and other steroid medications (treatment will increase inflammation)
  • Pregnant/Nursing
  • HIV/AIDS
  • Collagen vascular diseases
  • Anticoagulants / Blood thinners (including but limited to Warfarin or aspirin)
  • Nickel or stainless steel allergies
  • Scleroderma
  • Collagen vascular diseases
I have read and understand the above

Waiting times for specific procedures (on area to be treated)

  • Avoid the use of spray tans / fake tan creams for 2-3 weeks following the treatments
  • Recent facial operations - At least 3 months post surgery
  • Isoretinoin (e.g. Roaccutane) - 6 - 12 months post treatment
  • Tattooing / Cosmetic Tattooing - 3 months
  • IPL / Laser hair removal - 2 weeks
  • IPL skin treatments - 2 weeks
  • Laser Resurfacing/Ablative - 8 weeks
  • Strong chemical peels - PH lower than 3.1. - wait 2 weeks
  • Botulinum Toxin - 2 weeks
  • Dermal Fillers - Hyaluronic Acid & Vital Hydrate - 2 weeks
  • Dermal Fillers - Sculptra & Radiesse - 6 week

I have read and understand the above

Stop using/taking 1 week before commencing treatments:

  • Fish Oils / Plant oils / Omega 3s
  • Ginseng / Ginkgo Biloba / St. John's Wort
  • Retinoids
  • Topical antibiotics
  • Exfoliants and/or AHA or BHA
  • Benzoyl peroxide / adapalene (Differin)
  • Hydroquinone / kojic acid / azelaic acid
  • Anti-inflammatory medications such as ibuprofen. These will interfere with the natural inflammatory process that is critical for your skin rejuvenation - for microneedling only.
  • Waxing or depilatory creams on the area to be treated

I have read and understand the above

Recovery time:

  • 60 minutes: Reddening and possible pinpoint bleeding.
  • Up to 24 hours: erythema (reddening or rash like appearance), petechiae (pinpoint, round spots), minor edema (swelling)
  • 1-2 days: Mild erythema , petechiae, reduced edema, minor itching, dry/tight sensation.
  • 2-3 days Reduced erythema, fading petechiae, dissipated edema, reduced itching, minor skin flaking
  • 3-4 days: Potential dryness
  • 4-5 days: Full Recovery with normal function
  • 3 weeks: improved pigmentation begins
  • 4-6 weeks: Improvements in lines, wrinkles and scarring begins

I have read and understand the above

Post-Treatment:

Avoid the following activities for up to 2 days following a microneedling facial:

  • Direct ultraviolet exposure (sun and sunbeds)
  • Intensive cardio, exercise or gym regimens
  • Excessively hot showers, bathing, spas or sauna
  • Swimming in chlorinated pools or the ocean
  • Tattooing (including cosmetic tattooing)
  • Further clinical treatments should be avoided for up to two weeks including, but not limited to: Microdermabrasion, Laser, Intense pulsed light, Chemical peels, Muscle relaxant injections, Dermal fillers

Avoid the use of skin care products containing any of the following active resurfacing ingredients for up to 5 days following a microneedling clinical procedure:

  • Alpha hydroxy acids (AHAs) including but not limited to: Glycolic acid, Lactic acid, Malic acid
  • Beta hydroxy acid (BHA) including salicylic acid
  • Benzoyl peroxide
  • Retinoids, including but not limited to: Tretinoin, Retinol, Retinaldehyde
  • Hydroquinone
  • High levels of Kojic or Azelaic acid
  • Alcohol including but not limited to: Isopropyl alcohol, denatured alcohol, Rubbing alcohol

If in doubt with any of the above activities or products, please contact your Esthetician for clarification as to when normal activity or use may be resumed.

I have read and understand the above

Home Care:

  • For the first 1-3 days the skin may feel tight and dry. Frequent use of post session topical will help with this.
  • Light, non-occlusive and non-comedogenic make-up may be applied 24 hours post-procedure and a SPF 30 or above is advised for at least 3 days after your treatment.
  • After 2-3 days you can return to your regular skin care products with the exclusion of the products listed above
  • Low dose Vitamin A products are recommended
  • Avoid direct sunlight and always wear SPF30 or above. Do not apply a chemical sunscreen the same day as the treatment, only approved physical defense sunscreen can be used.
  • Microneedling serves to stimulate collagen and the skin can benefit from higher amounts of collagen than normal to have optimal results. Collagen stimulating peptides assist in this process.
  • It's important to hydrate before and after the procedure to help skin heal and rejuvenate faster.
  • Gently exfoliate the skin after 3-5 days to remove flaky skin that can form after the treatment.
  • Omega 3, Zinc & glucosamine oral supplements can help with your treatment results.

I have read and understand the above

I confirm that I have informed the staff regarding any current or past medical condition, disease or medication taken.

I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent form.

If you have additional questions or concerns regarding your treatment or suggested home regimen, you will consult your Esthetician immediately.

I have read and understand the above

Please check all consent and disclosure checkboxes.

Your form has been successfully submitted. Thank you!

Adult Signature:

Sign for Child: